Oxalate Nephropathy Due to Excessive Intake of Nuts

NKF 2016 Spring Clinical Meetings Abstracts

Case Report 121

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HOSPITAL TRANSFUSION USE AND INFECTION-RELATED OXALATE NEPHROPATHY DUE TO EXCESSIVE INTAKE OF RE-HOSPITALIZATION AMONG PATIENTS ON DIALYSIS: NUTS. M Gonzalez Suarez, L Cornell, S Herrmann; Mayo Clinic, David Gilbertson1, Suying Li1, Jiannong Liu1, James Wetmore1, Anne Rochester, MN, USA 2 Beaubrun2, Paul Dluzniewski2, Xinyue Wang1, Brian Bradbury2, Oxalate nephropathy (OxN) is associated to progressive renal injury MN, Chronic Disease Research Group1, Amgen Inc2, Minneapolis, due 1 to intratubular precipitation of calcium oxalate crystals. This leads 1, 1 Laith Al-Rabadi, MBBS, * Rivka Ayalon, MD, Bonegio, MD, PhD, Thousand Oaks, CA. to acuteRamon and chronicG. tubular injury, interstitial fibrosis, and progressive 2,y 3 4 Red blood cell Jennifer (RBC) transfusions (Tr) have been with renal failure. E. Ballard, MD,associated Alan M. Fujii, MD, Joel M. Henderson, MD, PhD, adverse outcomes, including infection, among patients with critical A 53 years old man with medical history of migraines, chronic 1 David J. Salant, MD, and Laurence H. Beck MD, PhD 1 anti-inflammatory conditions or undergoing cardiac surgery. Given the increase in Tr that kidney disease and Jr, chronic non-steroidal drugs use; followed the new bundled payment system and an erythropoiesis presented with worsening kidney function. No history of kidney stones stimulating agent label revision in 2011, it is important to understand or any family history of kidney disease. Creatinine (Cr) on presentation the impact ofThere transfusion practices on the risk of infection-related reis little information about pregnancy outcomes in patients active membranous nephropathy was 2.5 with mg/dL, up from his baseline Cr of 1.3 mg/dL.(MN), No proteinuria hospitalizations(IRRH) among patients receiving hemodialysis (HD). to M-typeorphospholipase hematuria was present. Kidney biopsy significant amount of (PLAshowed especially those with circulating autoantibodies A2 receptor 2R), the major We conducted a retrospective cohort study. Using the 2011 20% oxalate crystals. It was also seen interstitial autoantigen in primary MN. We present what we believe to intratubular be the firstpolarizable known case of successful pregnancy in Medicare general Medicare dataset, we first calculated hospital-level fibrosis. Serum oxalate level was 19.9 µmol/L. Urine oxalate was 132 year prior Patient’s to pregnancy, the patient a 39-year-old woman with aPLA 2R-associated adjusted odds ratios of receiving a Tr using mixed effect logistic MN. In themg/specimen. only risk factor for OxN developed was excessive dietary anasarca, hypoalbuminemia (albumin, 1.3-2.2 (protein excretion, 29.2 g/d).hyperoxaluria Kidney bi- was model. Hospitals were then categorized into quintiles of the Tr OR g/dL), and proteinuria intake of almonds. Genetic testing for primary distribution. Nextrevealed we identified patients receiving who and the patientnegative. was seropositive for anti-PLA2R autoantibodies. opsy MNallwith staining forin-center PLA2R,HD had an incident hospitalization eventtobetween 2012 andtherapy 2013 in the an uncommonrituximab presentation kidneyofinjury. Ethylene glycol She did not respond conservative and was treated OxN withisintravenous (2 of doses 1 g each). Medicare ESRD dataset. Using a grouped treatment approach, we used ingestion, bypass and surgery, and primary hyperoxaluria are Several weeks after presentation, she was found to be 6 weeks pregnant wasmalabsorption closely followed up without Poisson regression to estimate the association between hospital Tr use among the most common causes of OxN. In our patient, it was further immunosuppressive Proteinuria remained with protein excretion the 8to 12-g/d range. quintile and patient-level risk of IRRH withintreatment. 30 days in dialysis associated to excess of dietaryinoxalate intake. This case illustrates the declined but were still detectable. At 38 a healthy baby the girletiology was born, Circulating anti-PLA patients hospitalized 2012-2013, adjusting for patient demographics, 2R levels importance of aweeks, kidney biopsy to elucidate when comorbidities, and hospital and hospitalization without proteinuria at birth or atcharacteristics. her subsequent 6-month postnatal visit. Atinjury the time of delivery, still progressive renal without proteinuriathe has mother no clinical explanation. We identified 123,554 patients and 2,714anti-PLA hospitals. Patient had detectable circulating 2R of immunoglobulin G1 (IgG1), IgG3, and IgG4 subclasses, although at characteristics and hospitalization characteristics were generally low titers. Only trace adjusted amounts of IgG4 balanced across quintiles. Examining relative risks ofanti-PLA IRRH 2R were found in cord blood. Potential reasons for the in the maternal and fetal circulation are discussed. discrepancy between anti-PLA 2R levels by hospital-level transfusion probability, dose-response relationships across quintiles probability not observed forªprimary Am JofKidney Dis.were 67(5):775-778. 2016 or by the National Kidney Foundation, Inc. secondary outcomes. We additionally conducted a patient-level analysis and observed a significant association between Tr and IRRH INDEX WORDS: Membranous nephropathy (MN); nephrotic syndrome; pregnancy; M-type phospholipase A2 within 30 days; a minimally-adjusted HR = 1.17 (95% CI 1.13-1.22). Figure1. Hematoxylin eosin staining shows acute tubular injury receptor (PLA R); autoantibody; placenta; rituximab; immunoglobulin G (Ig G) and subclass. 2 Hospital transfusion practices were not associated with an increased in the renal cortex, with dilatation of the tubules and flattening of the risk of IRRH, although patients who did receive a transfusion were epithelium (left panel). Upon polarization (right panel), numerous more likely to be re-hospitalized. Additional research, possibly using an refractile calcium oxalate crystals are apparent. Glomeruli appear IV methodology, may be necessary to further elucidate potential infection-related effects of blood normal.100x magnification. regnant patients withtransfusions. autoimmune disease may CASE REPORT

Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report

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deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 122 circulating autoantibodies. Pregnant patients with OUTCOMES OF MODELS OF CARE IN END STAGE RENAL DISEASE: A lupus or myasthenia gravis can deliver babies with SYSTEMATIC REVIEW 1,2 M Gonzalez Suarez,disease P Ramar, L Hickson, B Thorsteinsdottir. Mayo corresponding in theS Chawla, neonate. Neonatal Clinic Rochester, MN, USA membranous nephropathy (MN) not associated with Healthcare reform drives the incentive to provide high quality of integrated health services at a lower cost for end stagedescribed renal disease (ESRD) patients.and congenital infection was first in 1990 This systematic review describes the impact of alternate models of care for attributed toonthe passive of maternal antiESRD patients important outcomestransfer including hospitalizations and mortality. 3 Multiple searched for comparative studiesthan published 2000bodies to databases putativewere renal antigens. More a decade 2014 with >5 dialysis patients over age 18 receiving treatment, >6 months of later, Debiec et al4 identified the first antigen involved follow up, and reporting mortality or hospitalization outcomes. Eligibility for in inclusion such was cases as neutral endopeptidase (NEP), determined with dual agreement and differences resolved by a a third investigator. Study quality was using Cochrane Newcastlemetalloprotease present onevaluated the surface of theandpodocyte Ottawa tools. and Out involved in the proteolytic regulation of vasoacof 1841 articles that were screened, 62 full texts were reviewed, and 16 with 72,395 patients were Mean followaupmother ranged from 9-96 a tivearticles peptides. Debiec et included. al described with months. Main sources of bias included representativeness and incomplete mutation preventing NEP expression who had formed follow up. Models of care comprised interventions targeting multiple aspects of ESRD patient care such as use of electronic patient record, nutrition, alternate anti-NEP antibodies due to fetomaternal alloimmudialysis settings and management, and involvement of multidisciplinary care nization from a previous miscarriage; these antibodies (MDC) team. Most studies were retrospective medical record reviews. High were to cross the due placenta andin populations, cause subepithelial heterogeneity was found to wide variation treatment settings, providers, of dialysis and intervention types.Most interventions deposits in themode fetal kidney of a subsequent pregwere effective in reducing mortality and hospitalizations, and MDC was nancy. M-type phospholipase A receptor (PLA consistently an important component. 2 2R) studyidentified provides evidence models of care, particularly was Our later as that thealternate major autoantigen forthose priwith MDC are effective in reducing 5 hospitalizations and mortality in ESRD mary MN instudies adults. Little literature existsof delivery about patients. Further are required to redesign current practices of care in ESRD population. in patients with nephrotic synpregnancy outcomes Intervention Studies MN, Patientswith Outcomes Reported drome due to primary no data available MDC pregnancy 8in PLA 12,769 Mortality, Hospitalizations about R-associated disease. We 2 Alternate Setting 5 25,738 Mortality, Hospitalizations present what we believe to be the first known case of Physician Visit 2 32,098 Mortality pregnancy in a patient with PLA MN 2R-associated Electronic Record 1 1790 Mortality, Hospitalizations who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118

A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 124

before her current pregnancy. She had been treated for resistant SELF-EFFICACY IN PATIENTS: HOW MARKETING hypertension and lower-extremity edema during the past year, ACTIONS AFFECT SOCIAL STIGMA AND PATIENTS’ butSELF-STIGMA her proteinuria had been overlooked. At presentation, serum creatinine level was 1.52 mg/dL (corresponding Renée Richardson Gosline, Massachusetts Institute ofto estimated glomerular filtration rate ofof46Management, mL/min/1.73 m2 as calculated Technology Sloan School Cambridge, MA, by theUSA isotope-dilution mass spectrometry–traceable 4-variable MDRD of Diet in Renal Disease] Study equaThere[Modification is a high prevalence of disease-specific marketing tion); serum albumin level, 1.5 g/dL;has andassessed 24-hourtheurine actions in the US, however, no study directprotein excretion, The kidney biopsy specimen revealed features effects of29.2 theseg.marketing actions on patient coping attitudes and typical of primary MN with staining the behaviors. Recent research hasadditional shown the strong power of “sad” orfor lowefficacy faces towithin invokeimmune sympath.deposits Another(Fig dominant messaging PLA S1). Many of the 2R antigen approach features images of high self-efficacy. How do these subepithelial deposits were completely surrounded by new ideal typesmembrane (victims andmaterial survivors)(Fig affectS2), behavior? basement and Using 35% of the controlled psychological experiments, we tested how disease perceptions, coping decisions, and disclosure behaviors of subjects are1affected by marketing images. In study one, results From the Department of Medicine, Renal Section, and Deshow that subjects exposed to more disease-related marketing4 3 partments of 2Obstetrics Gynecology, Pediatrics, and actions were significantlyand more willing engage in self-care in Pathology and Laboratory Boston Medical social settings and to takeMedicine, their diagnoses moreUniversity seriously. These Center, Boston, MA. attitudes were reflected in behaviors that included: drafting a * Current affiliation: Department Internal Medicine, Division will, wearing a medical ID bracelet,ofrequesting special dietary of menu Nephrology, University of Utah their School of Medicine, Salt Lake accommodation, disclosing disease, anticipating City, UT.understanding from others, joining a patient support greater y Current affiliation: Department andasking Gynecology, group, wearing a medical mask on of an Obstetrics airplane, and family and friends to shave Hospital their heads in show of solidarity.DC. Medstar Washington Center, Washington, In study June two, we subjects to and form low efficacy Received 29,exposed 2015. Accepted inhigh revised October 27, representations the sameonline disease. We find that 2015. Originally of published December 29, “sad” 2015. images increase amongsttonon-patients, but Beck that “strong” Address sympathy correspondence Laurence H. Jr, MD, PhD, images decrease self-stigma amongst patients.MA Together these Renal Section, X-504, 650 Albany St, Boston, 02118. E-mail: findings show that specific marketing actions may serve the dual [email protected] purpose anticipated social stigma as Inc. well as � 2016ofbyreducing the National Kidney Foundation, increasing self-care amongst patients. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A49